**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 3 of 4 residents (Residents 1, 2, and 3) reviewed for admission/readmission process remained free of significant medication errors. Failure to accurately review and transcribe admission orders for 2 of 4 residents (Residents 1 and 2) and failure to provide medications within physician prescribed medication parameters for 2 of 4 residents (Residents 2 and, 3). Resident 1's admission medication orders were not reconciled with the hospital discharge documents which resulted in the resident receiving two medications erroneously, including a blood thinner that had been listed as an allergy (with a note in the transfer order to NEVER go on a blood thinner again), which caused gastro-intestinal (GI) bleeding twice before; and resulted in the resident not receiving two medications should have been initiated upon admission to the facility. Resident 1 experienced harm when they urinated blood and had abdominal pain. These failures placed all residents at risk for serious medication errors, complications, and adverse health outcomes. On 01/30/2024 at 3:51 PM, the facility was notified of an Immediate Jeopardy (IJ) situation related to CFR 483.45 (f)(2)- F760 -Residents are Free of Significant Med (medication) Errors. The IJ was determined to have begun on 01/09/2024 when Resident 1 was readmitted to the facility. The IJ was removed on 01/31/2024 when the facility had assessed the admission order process and educated the licensed nurses and providers on the new admission order process. After removal of the IJ, the remaining noncompliance at F760 remained at an E scope and severity, a pattern with no actual harm, with potential for more than minimal harm. Findings included . Review of a facility policy, titled, Reconciliation of Medications on Admission, revised July 2017, showed: -Information used to reconcile the medication list was the admission order sheet and the discharge summary from the referring facility. - Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications for the purpose of preventing unintended changes or omissions at transition points in care. - Review the list carefully to determine if there were discrepancies/conflicts. - Document the medication discrepancy and what actions were taken to resolve the discrepancy. <RESIDENT 1> Resident 1 had been a resident of the facility since 10/27/2022. Their most recent admission was from the hospital on [DATE]. Resident 1's re-admitting diagnoses included upper gastrointestinal (GI) bleeding from stomach ulcers, acute blood loss anemia, Klebsiella bacteremia, sepsis (body attacks organs/tissues due to bacteremia), Pulmonary emboli (blood clots in lungs), deep vein thrombosis (blood clots in arms or legs), and ventilator dependent (use of machine to assist resident to breathe). Review of the facility risk management system report titled, medication, dated 01/24/2024, showed Collateral Contact 1 (CC1), Nurse Practitioner, notified the facility Resident 1 had received apixaban (blood thinner that decreases the risk of blood clotting) in error. The investigation showed Resident 1 had two documents on discharge, the Skilled Nursing Facility (SNF) hospital transfer orders and the critical care discharge (d/c) summary, which had conflicting information regarding what medications to order on admission to the facility. Review of the SNF hospital transfers orders, dated 01/09/2024, showed a medication allergy of apixaban. The medication list showed Resident 1 was to be on meropenem (antibiotic) thru intravenous (IV) every six hours for two days, and sucralfate (provides coating to stomach ulcer to protect it from stomach acid) four times a day. There was no documentation on the SNF transfer orders for Resident 1 to have apixaban or oxycodone (opioid medication) ordered when readmitted to the facility on [DATE]. Review of the hospital critical care d/c summary, dated 01/09/2024, showed Resident 1 had apixaban given in the hospital but it caused GI bleeding and had to be discontinued. The note showed Resident 1 should NEVER go on an anticoagulant (medication to thin blood) again. The critical care d/c summary had a section labeled expected medication list at discharge which showed apixaban and oxycodone as an order. The critical care d/c summary showed Resident 1 was to have meropenem IV every six hours for two days and sucralfate four times a day. Review of Resident 1's facility admission orders dated 01/09/2024, showed an order for apixaban twice a day with an order date of 12/15/2023. There was an order for oxycodone as needed with an order date of 12/16/2023. The facility admission orders did not have sucralfate or meropenem on admission to the facility. Review of CC1's progress note, dated 01/18/2024, showed facility staff had notified them that Resident 1 had gross hematuria (blood in urine) this morning. Review of a progress note, dated 01/20/2024 at 8:57 AM, showed Resident 1 had complained of abdominal pain at 1:26 AM. The progress noted showed Resident 1 had been found to have a stomach ulcer and was provided pain medication. At 1:45 AM, Resident 1 was found unresponsive and emergency services were summoned. Emergency services performed resuscitation without success and reported Resident 1's death at 2:45 AM. Review of the facility discharge summary, completed on 01/29/2024 by CC1, showed Resident 1's diagnosis as pneumonia with pulmonary emboli. During an interview on 01/30/2024 at 10:47 AM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated the process for admissions/readmissions was admission orders were inputted from the SNF hospital transfer orders and the d/c summary from the hospital. Staff D stated if the SNF hospital transfer orders and the d/c summary had conflicting information, the provider would need to be contacted and determine which medications to give. Staff D stated facility practice was to confirm admission orders with two nurses to verify accuracy, but there have been times when there haven't been two nurses available, so they had confirmed orders by themselves. During an interview on 01/30/2024 at 11:59 AM, Staff B, interim Director of Nursing Services, stated the SNF hospital transfer orders should be what the staff use to determine the medication orders for admission. Staff B stated two nurses should review admission orders. Staff B stated they expected the nurse to contact the provider if there was a discrepancy and document in the clinical record what the resolution was. Staff B stated there had been a medication error and Resident 1 should not have been given apixaban upon readmission to the facility. During an interview on 01/30/2024 at 12:43 PM, Staff C, RCM/LPN, stated they had done the readmission for Resident 1. Staff C stated the admission orders were compiled from the SNF hospital transfer orders. Staff C stated they had been the only nurse manager working on the day of readmission and did not have time to review the hospital documents. Staff C stated they looked at the SNF hospital transfer orders and noted there was no notation of having new or changed medications, so they just reactivated Resident 1's previous orders. Staff C stated they did not see apixaban had been added as an allergy on the SNF hospital transfer orders. Staff C stated they did not review the orders with the nurse practitioner, they had just left a note on their desk of Resident 1 being readmitted . During an interview on 02/02/2024 at 8:23 AM, Staff B stated they had reviewed hospital records and confirmed Resident 1 also had medication errors for sucralfate, meropenem and oxycodone. <RESIDENT 2> Resident 2 admitted to the facility on [DATE] and was most recently readmitted to the facility on [DATE], after a hospital stay from 01/05/2024 to 01/11/2024. Resident 2's diagnoses included pneumonia, chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood), and atrial fibrillation (a fast irregular heart rate). Resident 2 was significantly cognitively impaired. Review of Resident 2's SNF hospital transfer orders and the hospital d/c summary, dated 01/11/2024, included the following medications: -Vancomycin (an antibiotic) IV for three doses and to administer the first dose on 01/11/2024 at 9:00 PM. - Midodrine (medication to raise blood pressure) three times a day. The order had parameters to hold the medication if the systolic blood pressure (SBP - top number of blood pressure) was greater than 130. Review of Resident 2's facility January 2024 Order Summary Report, showed the following medications without clarification from the physician upon readmission to the facility on [DATE]: - Tylenol as needed (prn) every four hours for temp or mild pain, order date 08/26/2022. - Calcium-Vitamin D daily, order date 10/20/2023. - Fleet enema prn for constipation if no results from Dulcolax within two hours, order date 08/26/2022. - Ipratropium-albuterol inhalation 3 ml twice daily, order date 01/11/2024. - Milk of Magnesium as needed for constipation, order date 08/26/2022. - Senna oral syrup every 24 hours prn for constipation, order date 08/26/2022. Review of Resident 2's January 2024 Medication Administration Record (MAR), showed the following: -Vancomycin IV was started on 01/12/2024 at 9:00 AM (hospital orders stated to start on 01/11/2024 at 9:00 PM). - Amoxicillin (an antibiotic), ordered 01/04/2024, was administered on 01/11/2024 at 9:00 PM, without a current physician order. - Calcium-Vitamin D was administered daily from 01/12/2024 to 01/31/2024. - Ipratropium-albuterol which was ordered to be administered and was not on the January 2024 MAR, which was on the SNF hospital discharge orders and was ordered to be administered starting 01/11/2024. - Midodrine was administered three times daily at 9:00 AM, 1:00 PM, 9:00 PM, and was to be held if the SBP was greater than 130. The resident received midodrine as ordered, while in the facility, without documentation the SBP was being monitored. Review of Resident 2's nursing progress notes from 01/11/2024 through 01/29/2024, showed no documentation the facility had clarified the above medication discrepancies or notified the physician of the medication errors. Review of the EMR from 01/11/2024 through 01/29/2024, showed no documented SBP correlating with the time the medications were administered. During an interview on 02/02/2024 at 8:27 AM, Staff B stated if a medication had parameters for a blood pressure (BP), they would expect the nurse to check the BP before giving the medication and hold the dose if it was outside of the ordered parameters. Staff B reviewed the midodrine order on the January 2024 MAR for Resident 2. Staff B reported there were no BP's, but the nurses have other places to document BP readings and would follow up. During an interview on 02/02/2024 at 11:01 AM, Staff B reviewed the amoxicillin order on the January 2024 MAR and stated the amoxicillin had been documented as administered on 01/11/2024. Staff B reviewed the SNF transfer orders from the hospital and stated that it appeared the amoxicillin should not have been administered but they would have to check. During an interview on 02/07/2024 at 4:12P M, Staff B stated they had no further information for the amoxicillin given in error. Staff B deferred the BP readings for midodrine to Staff C. During an interview on 02/07/2024 at 4:57 PM, Staff C stated the midodrine order had not been entered correctly so there was no documentation the nurses were completing the BP's before administering the medication. <RESIDENT 3> Resident 3 admitted to the facility on [DATE] and was most recently readmitted to the facility on [DATE], after being hospitalized from [DATE] to 12/28/2023. Review of the resident's diagnoses included and infected wound on their coccyx (bottom), stroke, high blood pressure, tachycardia (a heart rhythm that beats faster than usual), and a persistent vegetative state. Review of Resident 3's SNF hospital transfer orders, dated 12/28/2023, included the following medications: -Albuterol nebulizer (a machine that turns liquid medications into a fine mist for easier absorption into the lungs) solution every six hours prn. - Bisacodyl suppository every day. Review of Resident 3's facility's Order Summary Report, date 12/28/2023, showed the following medications were not reconciled or clarified on readmission to the facility 12/28/2023 with the physician: -Albuterol prn every two hours (was ordered every six hours SNF hospital transfer orders), order date 12/08/2023. -Ascorbic Acid (vitamin C) every morning, order date 12/08/2023. -Bisacodyl suppository one as needed prn for constipation, order date 12/08/2023 (SNF hospital transfer orders directed the suppository to be daily). Additional review of the facility's 12/28/2023 Order Summary Report, showed the following medications with specific parameters of when to hold the mediation: -Lasix (a diuretic) every day and to hold the medication if the resident's SBP was below 110 or heart rate (HR) below 60 beat per minute (BPM), order date 12/08/2023. - Lisinopril (medication to treat high blood pressure) every day, and to hold the medication if the resident's SBP is below 110, order date 12/08/2023. -Propranolol (medication to treat an irregular heartbeat) 10 mg two tablets every eight hours, order date 01/04/2024. Licensed staff was directed to hold the medication if the resident's SBP was below 110 or their HR was below 60 BPM. Review of Resident 3's December 2023 and January 2024 MAR, showed: -Vitamin C was given 12/29/2023 to 01/30/2024, without an updated order from their readmit of 12/28/2023. - Lasix was administered five times in January when their SBP was below 110 (on 01/05/2024, 01/13/2024, 01/15/2024, 01/19/2024, and 1/24/2024). - Lisinopril was given five times when their SBP was below 110 (on 01/05/2024, 01/11/2024, 01/13/2024, 01/15/2024, and 01/24/2024). - Propranolol was to be administered at midnight, 8:00 AM and 4:00 PM. The medication was given six times when the resident's SBP was below 110 (01/04/2024, 01/05/2024, 01/13/2024, 01/15/2024, 01/17/2024 and 01/24/2024). The medication was not given five times (on 01/10/2024, 01/11/2024, 01/15/2024, 01/23/2024, and 01/26/02024) with a code documented on the MAR as an X (no correlating chart code on MAR and no recorded BP). Additionally, the medication was held four times (on 01/13/2024, 01/19/2024, 01/21/2024, and 01/26/2024) with a code documented on the MAR as HD=Hold/See Nurse Note, and held once on 01/08/2024 with a cod of NN-No / See Nurse Notes. Review of Resident 3's nursing progress notes, dated 01/01/2024 through 01/29/2024, showed no correlating documentation why the medication was held when per the directions on the January 2024 MAR, when the nurse coded a NN or a HD which directed the nurse to document in the progress notes. The progress notes did not reveal why the medication was not administered or their SBP or HR was not documented when the nurse documented an X on the January 2024 MAR. The nursing progress notes showed no documentation the facility had clarified the above medication discrepancies or notified the physician of the medication errors. During an interview on 02/02/2024 at 8:27 AM, Staff B stated if a medication had parameters for a BP, they would expect the nurse to check the blood pressure before giving the medication and hold the dose if it was outside of parameters. During an interview on 02/07/2024 at 4:57 PM, Staff C stated they had reviewed the BP's for Resident 3 on 01/04/2024, 01/05/2024, 01/13/2024, 01/15/2024, 01/16/2024, 01/17/2024, 01/19/2024 and 01/24/2024 and that the SBP was below 110. Staff C stated the nurses had given the medications outside of the ordered parameters and they would need education. WAC Reference 388-97-1060 (3)(k)(iii) This is a repeat citation from annual survey with exit date of 9/20/2023. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 66> Resident 66 admitted to the facility on [DATE] with diagnoses that included Diabetes Type 2, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and history of falling. In an interview and observation on 08/31/2023 at 10:34 AM, Resident 66 stated they have been taking medications to treat anxiety and depression for many decades. Resident 66 stated about once a year they see a provider that managed their psychotropic medications. Resident 66 stated they had been falling at home prior to hospitalization and while at the facility. Resident 66 stated they have been using hydroxyzine since early 2000. Resident 66 was observed lying in bed, stated they were tired, and wanted to sleep. Review of Resident 66's June 2023 MAR, showed an order for hydroxyzine every four hours PRN for anxiety for 14 days starting 06/15/2023. The resident received hydroxyzine one to three times a day during the 14 days period, the order ended on 06/30/2023. The nurses were directed to monitor for any antianxiety s/e's, specifically sedation, morning hangover, ataxia (a loss of coordination), and nausea every shift and were to document any s/e's in the progress notes. There were no documented side effects from 6/15/2023 through 06/29/2023. There were no behavioral monitors, documented signs, or symptoms of anxiety, or any non-pharmacological interventions used prior to the administration of the PRN antianxiety medication. Review of CC2's progress note, dated 07/05/2023, showed Resident 66's hydroxyzine had been discontinued a few days ago and the resident felt they were more anxious. The resident's use of the antidepressant alone was not enough for them as they had been taking hydroxyzine for years. CC2 ordered hydroxyzine 0.5 mg PRN every four hours for anxiety, with no indication regarding the duration of the PRN medication. Review of Resident 66's 07/01/2023 through 08/31/2023 MAR, showed on 07/05/2023 hydroxyzine 0.5 mg was started every four hours PRN for anxiety with no end date. The resident received hydroxyzine one to three times a day, except for two days in July and one to three time a day, except for three days in August. There were no behavioral monitors, documented signs or symptoms of anxiety, or any non-pharmacological interventions used prior to the administration of the PRN antianxiety medication. In an interview on 09/11/2023 at 12:01 PM, CC2 stated they did not know why Resident 66's hydroxyzine order was not changed from PRN to be administered daily. Reference: (WAC) 388-97-1060 (3)(k)(i)(4) <RESIDENT 14> Resident 14 was admitted to the facility on [DATE] with diagnoses to include Bipolar II disorder (mental illness characterized by depressive episodes and hypomanic episodes), panic disorder and anxiety disorder. Review of Resident 14's August 2023 MAR, showed Resident 14 had orders for: - lorazepam (antianxiety medications) 0.25 mg scheduled two times daily for anxiety, was initiated on 09/08/2022. - valproic acid (medication to treat seizures and bipolar disorder) 250 mg three times daily for bipolar disorder management, initiated on 04/22/2023. - hydroxyzine (an antihistamine antianxiety medication) 25 mg every six hours as needed (PRN) for itching or anxiety, initiated 08/15/2023, there was no stop date. Resident 14 received hydroxyzine nine times. There was no corresponding documented rational why the resident received the PRN medication. - fluoxetine (antidepressant/antianxiety medication) 40 mg daily for panic disorder. - lorazepam 0.25mg every six hours PRN for anxiety, panic attacks, initiated 08/14/2023, and was increased on 08/15/2023 to 0.5 mg every six hours PRN for anxiety, panic attacks. The resident received lorazepam six times with no corresponding documented rationale why they received the medication, why the medication was increased, or an order to stop the PRN medication after 14 days. Review of Resident 14's September 2023 MAR, showed Resident 14 received hydroxyzine PRN two times and lorazepam PRN zero times. There was no corresponding documented rationale why the resident received the medications, or an order to stop the PRN medication after 14 days. In an interview on 09/13/2023 at 10:35 AM with Staff G, Social Services Director stated the GDR's were documented under assessments and if unable to find it there, then a GDR had not been attempted. No further information was provided. In a joint interview on 09/14/2023 at 3:10 PM, Staff D, LPN/Resident Care Manager (RCM), stated they were unsure if there was a difference in processing a PRN order from a routine medication order. In this same interview, Staff C, LPN/RCM, stated that PRN psychotropic medication orders need to have a 14 day stop date, and then the resident was evaluated at that 14 day stop date. Staff C stated GDRs were documented under the assessments. No further information was provided. In an interview on 09/19/2023 at 10:07 AM, Staff B stated GDR's were completed quarterly. Staff B was unable to locate a GDR attempted for Resident 14. Review of Resident 14's EMR showed no documentation to support PRN hydroxyzine and lorazepam medications longer than 14 days. There was no GDR documentation located in the medical record regarding any of Resident 14's psychotropic medications. <RESIDENT 16> Resident 16 first admitted to the facility on [DATE] with a diagnosis of depression. Review of Resident 16's September 2023 physician orders, showed an order for mirtazapine (antidepressant) 45 mg once daily with an order date of 02/06/2023. Review of the medical record showed the resident readmitted to the facility on [DATE] after a hospital stay. Review of Resident 16's physician orders for mirtazapine, since their initial admit date of 06/03/2016, showed the resident had been on 45 mg once daily for depression, except for an attempted dose reduction down to 30 mg on 12/30/2016 thru 01/09/2017, at which time the dose was increased back to 45 mg. During an interview on 09/11/2023 at 10:43 AM, Staff G stated if the facility staff had reviewed a psychotropic medication for a dose reduction, the documentation would be on the psychotropic/therapeutic medication use evaluation form in the record. Review of the clinical record showed the last psychotropic/therapeutic medication use evaluation was completed on 04/14/2021. During an interview on 09/11/2023 at 2:41 PM, Staff G stated that if there has not been a psychotropic/therapeutic medication use evaluation completed since 04/14/2021, then there was no documentation of why the facility had not attempted a dose reduction in the past year for Resident 16's mirtazapine. Staff G stated that they cannot state the last time resident's mirtazapine was reviewed.Based on observation, interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for 4 of 5 residents (Residents 10, 14, 16, and 66) reviewed for unnecessary psychotropic medications. The facility did not have a system that consistently monitored target behaviors, ensured there were valid indications for use of antipsychotic medications, involved the interdisciplinary team (IDT) in medication management process, considered gradual dose reeducations (GDR), and consistently attempted behavioral interventions prior to medications use. Resident 10 experienced harm when they developed significant adverse side effects that were sleepiness and lethargy (fatigue, tiredness, and exhaustion both physically and mentally) which were side effects of antipsychotic medications after being administered unnecessary psychotropic medication without recognition or treatment by the facility. The lack of addressing the serious s/e and medication use without established need represented an Immediate Jeopardy (IJ) situation. On 09/15/2023 at 5:12 PM, the facility was notified of an Immediate Jeopardy (IJ) situations related to CFR 483.45(c)(3)(e)(1)(2)(d), F758, Unnecessary Psychotropic Medications, when the facility was found to be treating Resident 10 with the antipsychotic medication Seroquel for dementia with psychosis. Target behaviors were not consistently identified or consistently documented in 12 months, no GDR was documented, the facility failed to recognize and take action when staff identified in the progress notes the resident experienced adverse s/e's to include sleepiness and lethargy. Additionally, Resident 10 was treated with the psychotropic drugs duloxetine (an antidepressant medication) for depression, and trazodone (an antidepressant medication) for sleep. The facility was aware of the deficient practice on 09/15/2023 when they were notified of an Immediate Jeopardy situation by the survey team. The IJ was removed on 09/19/2023 after onsite validation by surveyor when review of Resident 10 and other residents that received psychotropic medications, verified the facility IDT collaborated with the residents provider and the pharmacist to ensure resident/s were reviewed for documentation to support appropriate diagnoses, indications, target behaviors, s/e's, gradual dose reductions, were addressed and documented. The facility provided education to licensed nurses, nursing assistants, the facility's Medical Director/Resident 10's physician and the nurse practitioner on the facility's policy and procedures related to the use of psychotropic medications. After removal of the IJ, the deficient practice at F758 remained at a G scope and severity, isolated, actual harm that is not immediate jeopardy, following the removal of the IJ. Findings included . Review of the facility policy titled, Psychoactive Drug Management, dated 09/20/2022, showed the purpose was to provide a therapeutic environment that supported residents to obtain or maintain the highest physical, mental, and psychosocial well-being. The policy identified antipsychotic medications, also called major tranquilizers, as the most powerful and dangerous of the psychotropic medications. The policy indicated: -Following admission, quarterly, annually and upon significant change of condition, the interdisciplinary team (IDT) will review and make recommendations based on resident needs to include: The effectiveness of non-drug interventions, the need for psychotropic medications, possible alternatives to use of psychotropic medications and possibility of dose reduction program. -If an antipsychotic medication was initiated within the last year, the facility has attempted a gradual dose reduction (GDR - a stepwise tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) between two separate quarters with at least one month in between attempts. If no antipsychotic GDR has been attempted, the prescriber has documented a tapering was clinically contraindicated (a symptom or medical condition that makes a particular treatment or procedure inadvisable because the resident is likely to have a bad reaction). -The pharmacy consultant and the IDT will reassess the resident at least quarterly to determine the effectiveness of psychoactive drug use. Any resident with a new antipsychotic medication order will be referred to the psychiatrist for review and will be reevaluated as needed. Any order for psychoactive medications must include the diagnosis for use, and specific behavior manifested. Non-drug (non-pharmacological - approaches to care that are provided as part of a supportive and psychosocial environment) interventions are documented and on the care plan. Review of the facility policy titled, Behavior Management, dated 02/01/2023, showed that residents exhibiting behavioral symptoms will be individually evaluated to determine the behavior. The IDT identifies the underlying concerns that contribute to changes in the resident's behavior. Staff will implement non-pharmacological interventions as the first line of approach to managing challenging behaviors. Behaviors and interventions will be addressed in the care plan. The facility will monitor identified residents who exhibit behavioral symptoms and refer the resident to mental health services if necessary. Review of the Food and Drug Administration (FDA) black box warning is the most serious type of warning issued by the FDA for certain medications that carry serious safety risks. Review of a black box warning showed, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. SEROQUEL is not approved for elderly patients with dementia-related psychosis. <RESIDENT 10> Resident 10 admitted to the facility 08/18/2022 with diagnoses to include fracture of a thoracic vertebra (a fracture of their back) and a fracture of their left radius (arm bone) sustained in a fall. Review of the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 08/25/2022, showed Resident 10 had severe cognitive impairment, had no psychotic disorder, no depression diagnoses, no behavioral symptoms documented, and did have symptoms of delirium to include inattention (lack of attention) and disorganized thinking. Review of Resident 10's hospital Discharge summary, dated [DATE], showed an order for quetiapine (Seroquel) 25 milligram (mg) two tablets twice daily as needed. The summary did not show no diagnoses of dementia, no psychiatric diagnosis, and quetiapine was a new medication for the resident. The resident had unchanged medications to include duloxetine and trazodone. Review of a Resident 10's Level I Pre-admission Screening and Resident Review (PASRR - a required screening form used to screen for a mental disorder or intellectual disability), dated 08/17/2022, showed the resident did not have dementia or a psychotic disorder, and they were not referred for a Level II evaluation (an evaluation for a mental disorder or intellectual disability). The PASRR identified the resident had a history of auditory hallucinations and required Haldol (antipsychotic medication) during their recent hospitalization, and was also started on Seroquel. The PASRR indicated the resident had no serious mental illness, intellectual disability, or related conditions. The PASRR identified it was negative PASRR. Review of the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 08/25/2022, showed Resident 10 had severe cognitive impairment, and did have symptoms of delirium to include inattention and disorganized thinking. The MDS did not show the resident had depression, behavioral symptoms, psychotic disorder or depression. Review of progress note, dated 08/24/2022, Staff G, Social Service Director, documented Resident 10's psychotropic medications initiation/increase due to dementia with associated behavioral symptoms as recorded on the behavior monitoring flow sheet. The reason for the increase was due the resident failed a GDR on admission and had an increase in behavioral symptoms. Review of Resident 10's medical records, showed no GDR's were attempted since the resident admitted to the facility on [DATE], there was no physician documentation that GDR's were contraindicated, and there were no corresponding behavior monitor flow sheets initiated on admission. Review of a Psychotropic/therapeutic Medication Use Evaluation, dated 08/24/2022, showed Resident 10's behavior symptoms have increased, in the past 30 days new medications (psychotherapeutic/antipsychotic) due to dementia with associated behavior symptoms as recorded on behavior monitoring flow record, and other dementia with psychosis. Staff were to monitor medication s/e's refer to Behavior Monitoring and Interventions flow record and MAR. Review of Resident 10's Psychotropic/therapeutic Medication Use Evaluation, dated 09/07/2022, showed: - Other concurrent clinical concerns, falls, insomnia, pain, - In the past 30 days new meds have been initiated (psychotherapeutic/antipsychotic), target behaviors hallucinations/delusional thoughts. - Reason for medication Initiation or Increase: Dementia with associated behavior symptoms as recorded on behavior Monitoring flow record. - Psychotherapeutic med: Seroquel 25mg twice daily, last dose change was on 09/01/2022. - Medication s/e monitoring: no s/e's noted. Review of Resident 10's focused care plan problem At risk for complications related to the use of psychotropic drugs, dated 08/30/2023, showed care plan interventions to include: Complete behavior monitor flow sheet, GDR's as ordered, monitor for changes in mental status and report to the physician if indicated, monitor for continued need for medication as related to behavior and mood, monitor for s/e's and consult with physician or pharmacists as needed, and obtain a psych evaluation as order. Review of Resident 10's Medication Administration Records/Treatment Administration Records (MARs/TARs) for 08/18/2022 through 09/14/2023, showed: -orders for Duloxetine twice daily for depression, started in August 2022 through September 2023, no target behavior monitoring was found in August 2022. This was not implemented until 09/01/2022. There was documentation they had a target behavior on 09/12/2022, but there was no explanation in the related nursing progress notes what it was. There were no documented target behaviors or adverse s/e's from October 2022 - 09/15/2023. -orders for trazodone for depression and insomnia, started in August 2022 through September 2023 (except for the time periods they were hospitalized ), no target behavior monitoring, or adverse s/e's monitoring were found in August 2022, and sleep monitoring was not implemented until 09/07/2022. There were no documented adverse s/e's from October 2022 - 09/15/2023. The facility failed to monitor the resident's treatment for insomnia/sleep from February 2023 - 09/14/2023 despite being administered trazodone for insomnia. -multiple orders for Seroquel: In August 18, 2022, the resident was admitted with as-needed Seroquel, then the order progressed to scheduled Seroquel once daily, on 08/24/2022. On 08/29/2022, the Seroquel was increased to twice daily. The order was decreased to once daily Seroquel on 09/01/2022 due to the resident was having symptoms that included drowsiness and not being as alert and conversant as they usually were. Except for their hospitalization in January 2023, the resident was continued on Seroquel once daily from 09/01/2022 through 09/15/2023. There was no documentation of target behavior monitoring or adverse s/e monitoring at all in August 2022. On 09/01/2022, staff implemented target behavior monitoring for hallucinations and delusional thoughts and started adverse s/e's monitoring. There was a documented target behavior documented on 09/12/2022, but no explanatory information was found in the nursing progress notes. There were no documented target behaviors from 09/13/2022 - 09/15/2023, except for on 03/18/2023, 03/19/2023, 03/25/2023 and 03/26/2023, when the nurse documented a 2 on the behavior monitor which indicated the resident had delusional thoughts. There was no corresponding progress note for those four days explaining how those target behaviors had manifested. There were no documented adverse s/e's documented on the Seroquel side effect monitor from September 2022 - 09/15/2023. Review of a provider notification note, dated 05/04/2023, showed Resident 10 was lethargic and confused. Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner, CC2 reviewed the notification on 05/05/2023 and would evaluate the resident. Review of CC2's note, dated 05/05/2023 at 00:00 (timed stamped in the electronic medical record), showed Resident 10 appeared to be more lethargic and confused than previous visits. The note did not contain further documentation regarding contributing factors to their increase in lethargy and confusion). Review of a provider notification note, dated 05/11/2023, showed the resident was tired and sleepy. Their blood pressure was 210/96 (high). CC2 signed the notification on 05/12/2023 and ordered a high blood pressure medication to be given as needed. Review of CC2's notes, dated 05/24/2023, 05/26/2023, 05/30/2023, 05/31/2023, 06/02/2023, 06/06/2023 and 06/15/2023 at 00:00, showed Resident 10 was sitting up in wheelchair (w/c) asleep. Review of CC2's note, dated 06/19/2023, showed Resident 10 was seen for follow-up after the resident had a fall and was seen in the emergency department (ED) on 06/15/2023. The resident did not have any severe injuries. Review of CC2's note, dated 06/26/2023, showed Resident 10 was sitting up in their w/c sleeping. The resident was arousable but fell asleep right away and had been feeling very fatigued. The resident's general exam was . Sitting up in wheelchair asleep . Review of the Annual MDS assessment, dated 06/27/2023, showed Resident 10 had severe cognitive impairment, had no delusions, no hallucinations, no behavioral symptoms, no signs or symptoms of delirium, and no psychotic disorder. Review of a provider notification note, dated 06/29/2023, showed a Licensed Practical Nurse (LPN), notified provider Resident 10 was lethargic and sleepy on the day shift. CC2 reviewed the note on 07/03/2023 and would evaluate the resident. Review of CC2's note, dated 06/29/2023, showed Resident 10 was lying in bed, lethargic but arousable. The resident had recurrent major depression, had been calling family sobbing and expressed they wished to live with their family again. Family reported the resident has been very tearful the last few weeks and they were concerned about the resident's mental health. Currently there were no behavioral health specialists (BHS) providers in the facility. Will need to obtain a psychiatrist evaluation when available again. Review of CC2's note, dated 07/05/2023, showed Resident 10 was seen sitting up in their w/c with family at the bedside. The resident was alert but falls asleep quickly while sitting up. Resident 10's family was concerned regarding the resident's mental status because they were calling them more frequently at night and more agitated with confusion of where they were. CC2 documented to obtain a psychiatrist evaluation when available again. Review of CC3's, physician, progress note, dated 07/07/2023, showed Resident 10's physical exam was they were in their wheelchair (w/c) in no acute distress and fatigued. Their assessment included dementia with psychosis, frequently confused, and was unsure of where they were. Review of CC2's note, dated 07/10/2023 and 07/12/2023, showed Resident 10 was sitting in their w/c, drowsy but arousable, diagnosis of dementia with psychosis, frequently confused and was unsure of where they were. Review of CC2's note, dated 07/14/2023, 07/17/2023, 07/18/2023, and 07/19/2023, showed Resident 10 was sitting up in their w/c drowsy but arousable. Review of CC2's note, dated 07/20/2023, showed the resident had been more lethargic, more frequently, and the family noticed Resident 10 had a decrease in their mood. Despite resident's increased tearfulness . CC2 was hesitant to increase Resident 10's trazodone related to the resident started to have falls and confusion from low oxygen levels. The resident would need to have a psychiatrist evaluation when available again. Review of CC2's note, note dated 07/21/2023, 07/27/2023, 08/01/2023, 08/02/2023, and 08/08/2023, showed Resident 10 was sitting in their w/c, drowsy but arousable, diagnoses of dementia with psychosis, frequently confused and was unsure of where they were. Review of CC2's note, dated 08/09/2023, showed Resident 10 was sitting in their w/c drowsy, arousable, initially agitated, and confrontational. Oxygen was placed on the resident, became less agitated, and then was pleasantly confused. The general assessment indicated the resident had dementia with psychosis, was frequently confused, and they were unsure where they were. Review of CC2's note, dated 08/10/2023 and 08/14/2023, showed Resident 10 was sitting in their w/c, drowsy but arousable, diagnoses of dementia with psychosis, frequently confused and was unsure of where they were. Review of a nursing progress note, dated 08/17/2023 at 3:02 PM, showed Resident 10 had increased confusion, and was sent to hospital for jerky movements and a shaky body. Review of CC'2, dated 08/17/2023, showed Resident 10 with a new onset of myoclonus (involuntary muscle jerks that can be from chemical or drug intoxication which included anti-psychotics or antidepressants). The resident was sitting in their wheelchair (w/c) drowsy but arousable, having severe intermittent myoclonus which almost led the resident to near falls from their w/c. The resident was transferred to the ED for further evaluation. On 08/28/2023 at 11:26 AM, Resident 10 was observed asleep in their bed. On 09/01/2023 at 9:26 AM, Resident 10 was observed in their room asleep sitting in their w/c. On 09/04/2023 at 10:35 AM and 12:30 PM, Resident 10 was observed asleep in their w/c beside their bed. On 09/08/2023 at 7:59 AM, Resident 10 was observed asleep in their bed. At 9:15 AM, the resident was observed in their room asleep in their w/c. In an interview on 09/08/2023 at 10:08 AM, Staff G, Social Services Director, stated they could not find documentation Resident 10 had experienced any hallucinations or delusions since they admitted in August 2022. Staff G said the facility had not been having quarterly behavior or interdisciplinary team (IDT) meetings regarding the use of the resident's psychotropic medications, and stated, truthfully we need to get better at that. Staff G stated Resident 10 had not been evaluated by a psychiatrist, but they've wanted to do that. Staff G stated they were involved in the resident's psychotropic medication monitoring process and no GDRs had been attempted. Staff G stated they did not think Resident 10's PASRR (dated 08/17/2022) was correct and the resident needed a new PASRR. Staff G stated the resident's medical record was not accurate to support the use of their psychotropic medications. On 09/08/2023 at 11:35 AM, CC4 and CC5, two of Resident 10's family members, were interviewed. CC5 stated Resident 10 had been very sleepy, and last week they were unable to wake the resident when they visited. CC5 stated they did not know of any psychiatric diagnoses the resident may have had. CC4 stated Resident 10 did not have a diagnosis of dementia or psychosis. CC4 stated Resident 10 did have some hallucinations or delusions, but that was more related to when the resident was in the hospital, and the hospital staff asked them to stay to help calm Resident 10 down. When asked about the facility had documented the resident had been taking an antipsychotic medication for years, CC4 stated that had just been when the resident was in the hospital, and it was related to them receiving Percocet (a potent opioid used for pain management). CC4 stated the resident was very sleepy all the time, and they felt it was medication related. CC4 stated staff have told them the resident woke up early in the morning and stayed awake. CC4 stated they think the resident had some Sundowners syndrome (a state of confusion occurring in the late afternoon and lasting into the night) which caused them some confusion, and this had been present for a while. In an interview on 09/08/2023 at 12:04 PM, CC1, Consultant Pharmacist, stated they had missed that there was no sleep monitoring in place since February 2023 for Resident 10, they were not aware of the resident's three falls as they were not notified by the facility, they had not identified any irregularities in the Medication Regimen Review (MRR) since February 2023, they were not aware of any target behaviors or s/e's, and they had not recommended any gradual dose reductions (GDR). CC1 stated they were not aware of any target behaviors being identified, and they were unaware the resident had experienced any s/e's, and if they did, they would have used that information. CC1 did not read progress residents' progress notes unless they had been alerted by staff of a concern. CC1 was asked about Resident 10's clinical indications for use of the Seroquel, they stated the resident had a diagnosis of psychosis so that was good enough for them. CC1 was unable to state when they had last attended a GDR meeting, they stated they thought the meetings were monthly, but the facility moved the appointments. On 09/08/2023 at 1:57 PM, Resident 10 was observed asleep in bed. On 09/11/2023 at 8:25 AM, Resident 10 was observed asleep in bed with the room lights on and their breakfast tray sitting untouched on bedside table. An interview was done on 09/12/2023 at 11:00 AM, with CC2 and Staff II, physician/Medical Director, and Staff B, Director of Nursing Services. Staff II and CC2 were not able to provide any information what the clinical indications were for Resident 10's treatment with Seroquel. Staff B stated the Seroquel was used due to the resident was being treated for dementia with psychosis and they had increased behaviors. The staff were asked regarding psychiatrist evaluation per CC2's progress note, dated 07/05/2023, CC2 stated this I write referrals, they take months. Review of the EMR, showed as of 09/12/2023 Resident 10 had not yet been evaluated by a psychiatrist. On 09/13/2023 at 8:25 AM, Resident 10 was observed asleep in bed with their breakfast tray on over bed table in front of them untouched. At 10:39 AM, the resident was observed asleep in their w/c sitting in front of the sink with their mouth wide open. On 09/13/2023 at 1:11 PM, Resident 10 was observed asleep in their w/c. In an observation and interview on 09/13/2023 at 2:41 PM, Resident 10 was sitting in their w/c, and stated I'm just sitting here trying to keep my eyes open, I'm so sleepy all the time, I just don't know why. Resident 10 stated the whole day went by today and they did not remember a thing, On 09/14/2023 at 8:35 AM, Resident 10 was observed asleep sitting at the edge of the bed with their arm resting on the bedside table and their head was resting on their arm. At 9:45 AM and 1:40 PM, the resident was asleep in bed with their mouth wide open. In an interview on 09/14/2023 at 1:40 PM, Staff U, [NAME] President of Operations, stated the doctor was only able to give information back as well as the information staff give to them. On 09/15/2023 at 8:29 AM, Resident 10 was observed asleep in their w/c.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 34> Review of Resident 34's August 2023 MARs, showed a physician order for Novolog (rapid acting) insulin four times a day, scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. 45 of the 124 doses administered were documented as given outside of the one-hour window. Two of the doses were administered over four hours late. On 08/08/2023 the 6:00 AM dose was documented as given at 10:41 AM, and on 08/15/2023 the 12 AM dose was documented as given at 4:41 AM. Three times the insulin dose was not held and administered when the resident's BG was < (less than) 140, on 08/01/2023 at 12:00 PM when the BG was 119, on 8/02/2023 at 6:00 PM when the BG was 129, and on 08/27/2023 at 6:00 PM when the BG was 129. There was no documentation in the EMR indicating why the insulin was not held or if the physician had been notified. Review of Resident 34's physician orders included Levemir (extended release) insulin two times daily at 9:00 AM and 9:00 PM. There were 23 of the 62 doses were documented as given outside the one-hour window. There were 10 doses that were documented as given more than four hours late on 08/02/2023 at 9:00 AM dose was documented as given at 1:27 PM, 08/03/2023 at 9:00 AM dose was documented as given at 1:26 PM, 08/07/2023 at 9:00 AM dose was documented as given at 2:09 PM, 08/14/2023 at 9:00 AM dose was documented as given at 1:48 PM, 08/17/2023 at 9:00 AM dose was documented as given at 1:46 PM, 08/20/2023 at 9:00 AM dose was documented as given at 1:44 PM, 08/22/2023 at 9:00 AM dose was documented as given at 1:18 PM, 08/26/2023 at 9:00 AM dose was documented as given at 1:08 PM, 08/27/2023 at 9:00 PM dose was documented as given at 1:07 AM on 08/28/2023, and on 08/30/2023 at 9:00 AM dose was documented as given at 2:41 PM. In an interview on 08/31/2023 at 5:21 PM, Staff N, LPN, stated when they only had two nurses on the unit, they could not get their medications administered timely. <RESIDENT 20> Review of Resident 20's August 2023 MARs, showed a physician order for lispro (rapid acting) insulin every six hours at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Resident 20 was to have the insulin dose based on the BG results. Resident 20 had a physician order for insta-glucose (used to treat low BG levels) as needed for BG less than 70. The resident had scheduled mealtimes at 7:50 AM for breakfast, 11:50 AM for lunch, and 5:00 PM for dinner. Resident 20 had been administered lispro insulin on 12:42 AM on 08/02/2023 with subsequent BG on 08/02/2023 at 6:00 AM was 47. Resident 20 had been administered lispro insulin on 2:43 AM on 08/04/2023 (over nine hours after resident's last meal) with subsequent BG on 08/04/2023 at 6:00 AM was 47. On 08/08/2023 at 6:00 AM, resident 20's BG level was 60. Resident 20 had been administered lispro insulin on 1:47 AM on 08/25/2023 (over eight hours after last meal) with subsequent BG on 08/25/2023 at 6:00 AM was 58. Review of the progress notes and MAR showed no documentation that insta-glucose was given per orders, no nursing documentation regarding the resident's condition and the physician was not notified when they had a low BG. Resident 20 had a physician order for glargine (extended release) insulin 32 units one time a day scheduled at 6:00 AM and glargine insulin 26 units once a day scheduled at 9:00 PM. There were no parameters in the physician orders to hold the glargine insulin based on the BG results. The glargine insulin was not given at 6:00 AM on 08/08/2023, 08/09/2023, 08/10/2023, 08/17/2023, 08/23/2023, 08/24/2023, 08/25/2023, 08/29/2023, and 08/30/2023. The MAR showed a code of NG. According to the key on the MAR, NG meant the medication was not given as parameters were out of range. There were no progress notes to explain why the medication was not given as ordered or that the MD was notified. Resident had ten out of 52 doses of glargine insulin administered during the month outside of the one-hour window to provide medications. Review of Resident 20's MAR, dated 09/07/2023, showed all of their 8:00 AM medications were administered late. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. <RESIDENT 21> Review of Resident 21's August 2023 MARs, showed an order for Humalog insulin before meals and to hold dose if BG <150. There was no documentation of the BG levels documented on the MAR. Seventeen of the 70 doses of Humalog administered were documented outside of the one-hour window, and three doses were documented as given more than four hours late: on 08/09/2023 the scheduled 4:30 PM dose was documented as given at 10:19 PM, on 08/18/2023 the 4:30 PM dose was documented as given at 11:32 PM (a BG was documented in the vital sign section with value of 179 done at 11:30 PM), and on 08/28/2023 the 4:30 PM dose was documented as given at 11:10 PM. Review of the August 2023 MAR, showed Resident 21 had a physician order for glargine insulin twice a day. Twelve of the 62 doses administered were documented outside of the one-hour window, and on 08/14/2023 at 8:00 AM the insulin was documented as given at 1:17 PM, more than four hours late. <RESIDENT 66> Review of Resident 66's August 2023 MARs, showed a physician order for lispro insulin twice a day at 4:30 PM and 9:00 PM. Staff were to hold the dose if the BG was <150. The lispro was administered four times during the month when the BG was <150: on 08/01/2023 the BG was 117, on 08/12/2023 the BG was 147, on 08/19/2023 the BG was 115 and on 08/20/2023 the BG was 139. Review of the August 2023 MARs, showed Resident 66 had 24 of the 62 doses of lispro insulin administered outside of the one-hour window. There were three incidents when the lispro insulin was given more than three and a half hours late: on 08/03/2023 the 9:00 PM dose of insulin was documented as administered at 1:23 AM (on 08/04/2023), on 08/14/2023 the 9:00 PM dose was documented as administered at 1:56 AM (on 08/15/2023), and on 08/25/2023 the 9:00 PM dose was documented as given at 12:28 AM (on 08/26/2023). Review of the August 2023 MARs, showed Resident 66 had an order for glargine insulin scheduled twice a day at 11:00 AM and 8:00 PM. The MAR showed 27 of the 62 doses of glargine insulin was administered outside of the one-hour window. There were two incidents when the glargine insulin was given more than five hours late: on 08/03/2023 the 8:00 PM dose was documented as administered at 1:22 AM (on 08/04/2023), and on 08/18/2023 the 8:00 PM dose was documented as administered at 2:15 AM (on 08/19/2023). Review of Resident 66's MAR, dated 09/07/2023, showed all of their 8:00 AM medications were administered late. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. <RESIDENT 2> Resident 2 had scheduled mealtimes at 7:50 AM, 12:00 PM, and 5:00 PM. Review of the August 2023 MARs, showed Resident 2 had a physician order for Humalog insulin before meals scheduled at 6:30 AM (over an hour before breakfast), 11:30 AM and 4:30 PM. Resident 2 had a physician order for Humalog insulin coverage before meals, based on the results of the BG, scheduled at 8:00 AM, 12:00 PM and 5:00 PM. Documentation showed nurses often administered the resident two separate injections of Humalog rather than combining the dose, causing Resident 2 to have additional injections. On the following dates and times, Resident 2 received an additional injection: 08/02/2023 breakfast and lunch doses, 08/03/2023 breakfast dose, 08/04/2023 lunch dose, 08/05/2023 lunch dose, 08/06/2023 dinner dose, 08/08/2023 dinner dose, 08/09/2023 lunch dose, 08/10/2023 lunch dose, 08/11/2023 lunch dose, 08/12/2023 lunch dose, 08/13/2023 dinner dose, 08/16/2023 lunch dose, 08/17/2023 lunch dose, 08/19/2023 breakfast dose, 08/21/2023 breakfast dose, 08/22/2023 breakfast and lunch dose, 08/25/2023 lunch and dinner dose, and 08/26/2023 breakfast, lunch and dinner dose. Review of the August 2023 MARs, showed Resident 2's Humalog insulin was documented as administered outside of the one-hour window 23 out of 110 doses. There were five doses documented as administered more than four hours late: on 08/03/2023 4:30 PM the insulin was documented as given at 8:46 PM, on 08/13/2023 the 6:30 AM dose and 11:30 AM dose were documented as administered at the same time at 11:11 AM, on 08/13/2023 the 5:00 PM dose was documented as administered at 6:22 PM, on 08/24/2023 the 4:30 PM dose was documented as given at 10:36 PM, and 08/26/2023 the 5:00 PM dose was documented as given at 6:24 PM. Resident 2 had a physician order for glargine insulin twice a day. Review of the August 2023 MAR, showed 21 of the 58 doses of glargine insulin was documented as administered outside of the one-hour window. Two doses were documented as administered more than four hours late: on 08/14/2023 the 8 PM dose was documented as given at 11:46 PM, and on 08/15/2023 the 8:00 AM dose was documented as given at 11:16 AM. On 08/31/2023 at 10:50 AM, Staff P, LPN, was observed to leave Resident 2's room and stated they had administered the resident's morning medications late because they were very busy and didn't have enough time to get medications administered in time. Review of the 08/31/2023 MAR, showed Resident 2 received three high blood pressure medications, pain medications, a bowel medication, vitamins, and an aspirin at 10:50 AM. The medications were all given late, as they were scheduled at 08:00 AM. In an interview on 08/31/2023 at 11:15 AM, Staff C stated they had talked to Staff P and they had not told them they were late with Resident 2's medications that morning, but that they had forgot to save them in the EMR when they had administered the medications. Staff P stated they were medication errors, and they would investigate them. <RESIDENT 13> Resident 13 had scheduled mealtimes at 7:50 AM, 12:00 PM, and 5:00 PM. Review of the August 2023 MARs showed Resident 13 had a physician order for lispro (rapid acting) insulin before meals. The order showed staff were to hold dose per hypoglycemia protocol, but Resident 13 did not have orders for hypoglycemia protocol on their MAR. Lispro insulin administration was documented outside of the one-hour window 13 out of 71 times. Three doses were documented as administered more than four hours late: on 08/24/2023 the 7:30 AM dose was documented as administered at 2:00 PM, and the 11:30 AM dose was documented at 2:03 PM. On 08/30/2023 the 4:30 PM lispro insulin was documented as given at 12:04 AM (on 08/31/2023). Review of the August 2023 MARs, showed Resident 13 had a physician order for glargine insulin twice a day. The staff were to hold the dose of insulin when the BG was <100. On 08/04/2023, the dose was not administered and showed a BG of 113 with a code of NG was documented on the MAR. There were no progress notes to explain why the medication was not given as ordered. Glargine insulin was documented as administered outside of the one-hour timeframe 17 out of 55 doses. Four doses were documented as given more than four hours late: on 08/07/2023 the 8:00 PM dose was documented as given at 12:31 AM (on 08/08/2023), on 08/11/2023 the 8:00 PM dose was documented as given at 12:53 AM (on 08/12/2023), on 08/15/2023 the 8:00 PM dose was documented as given at 12:46 AM (on 08/16/2023), and on 08/30/2023 the 8:00 PM dose was documented as given at 12:08 AM (on 08/31/2023). Review of Resident 13's MAR, dated 09/07/2023, showed all of their 8:00 AM medications were administered late. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. <RESIDENT 22> Resident 22 had scheduled mealtimes at 7:50 AM, 12:00 PM and 5:00 PM. Review of the August 2023 MARs, showed Resident 22 had a physician order for Humalog insulin with meals. Staff were to hold the insulin dose when the BG was <150. Ten of the 91 doses administered were documented outside of the one-hour window. Three doses were documented as being given more than four hours late: on 08/14/2023 the 5:00 PM dose was documented as given at 9:04 PM, on 08/18/2023 the 5:00 PM dose was documented as given at 10:14 PM, and on 08/30/2023 the 5:00 PM dose was documented as given at 8:56 PM. Three times the Humalog insulin was given when the BG was <150: on 08/07/2023 at 8:00 AM the BG was 130, on 08/21/2023 at 8:00 AM the BG was 144, and on 08/27/2023 at 8:00 AM the BG was 118. Review of the August 2023 MARs, showed Resident 22 had a physician order for glargine insulin twice a day. There were 16 out of 61 administered doses of glargine insulin documented as given one-hour outside of window. Five doses were documented as being given more than four hours late: on 08/14/2023 the 5:00 PM dose was documented as given at 9:04 PM, on 08/15/2023 the 7:00 AM dose was documented as given at 2:29 PM, on 08/18/2023 the 5:00 PM dose was documented as given at 11:15 PM, on 08/25/2023 the 5:00 PM dose was documented as given at 9:17 PM, and on 08/29/2023 the 5:00 PM dose was documented as given at 10:07 PM. <RESIDENT 40> Review of the August 2023 MARs showed Resident 40 had a physician order for Humalog insulin with meals and bedtime. Ten of the 49 doses administered were documented outside of the one-hour window. One dose was documented as being given more than four hours late: on 08/03/2023 the 9:00 PM dose was documented as given at 1:56 AM (on 08/04/2023). Resident 40 had a physician order for glargine insulin once daily scheduled at 8:00 PM. There were no parameters in the physician orders to hold the insulin based on the BG reading. The glargine insulin was not given on 08/02/2023, 08/04/2023, 08/05/2023, 08/08/2023, 08/10/2023, 08/12/2023, 08/14/2023, 08/16/2023, 08/18/2023, 08/20/2023, 08/22/2023, 08/23/2023, 08/24/2023, 08/25/2023, 08/28/2023, and 08/30/2023 with a code of NG shown on the MAR. There were no progress notes to explain why the medication was not given as ordered. Six of the 14 doses of glargine insulin administered were documented outside of the one-hour window. Two doses were documented as given more than four hours late: on 08/03/2023 the 8:00 PM dose was documented as given at 1:55 AM (on 08/04/2023) and on 08/07/2023 the 8:00 PM dose was documented as given at 12:09 AM (on 08/08/2023). <RESIDENT 33> Review of Resident 33's August 2023 MARs showed an order for Novolog (rapid acting) insulin before meals. Out of the 91 doses of Novolog administered, 32 were documented outside of the one-hour window. Five doses were documented as given more than four hours late: on 08/05/2023 the 7:00 AM dose was documented as given at 1:19 PM, on 08/07/2023 the 7:00 AM dose was documented as given at 12:54 PM, on 08/08/2023 the 7:00 AM dose was documented as given at 2:29 PM, on 08/30/2023 the 11:00 AM dose was documented as given at 3:31 PM and on 08/31/2023 the 7:00 AM dose was documented as given at 12:26 PM. Resident 33 had a physician order for glargine insulin twice a day. Review of the August 2023 MAR showed on 08/13/2023 the 8:00 PM dose was not signed as given and the MAR was blank. Out of the 59 doses administered, 38 were documented outside of the one-hour window. Five doses were documented as given more than four hours late: on 08/05/2023 the 8:00 AM dose was documented as given at 1:20 PM, on 08/07/2023 the 8:00 AM dose was documented as given at 12:54 PM, on 08/08/2023 the 8:00 AM dose was documented as given at 2:29 PM, on 08/19/2023 the 8:00 AM dose was documented as given at 1:49 PM, and on 08/20/2023 the 8:00 AM dose was documented as given at 12:02 PM. <RESIDENT 51> Review of the August 2023 MARs, showed Resident 51 had an order for glargine insulin twice a day. Staff were to hold the glargine insulin when the BG was < 100. Out of the 24 doses administered, 21 were documented as given outside of the one-hour window. Four doses were documented as being given more than four hours late: on 08/01/2023 the 7:00 AM dose was documented as given at 5:43 PM, on 08/04/2023 the 7:00 AM dose was documented as given at 11:54 AM, on 08/08/2023 the 7:00 AM dose was documented as given at 11:01 AM, and on 08/31/2023 the 7:00 AM dose was documented as given at 2:29 PM. The dose of glargine was not held on 08/04/2023 at 7:00 AM when the BG was 94. The 7:00 AM dose 08/16/2023 was blank on the MAR, which indicated that the medication was not provided. Review of Resident 51's MAR, dated 09/07/2023, showed all of their 8:00 AM medications were administered late. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. <RESIDENT 46> Review of Resident 46's August 2023 MARs, showed a physician order for Humalog insulin three times daily. There were 19 out of 89 doses administered were documented as given outside of the one-hour window. Six doses were documented as being given more than three and a half hours late: on 08/02/2023 the 4:30 PM dose was documented as given at 9:44 PM, on 08/05/2023 the 4:30 PM dose was documented as given at 7:08 PM, on 08/07/2023 the 4:30 PM dose was documented as given at 10:46 PM, on 08/10/2023 the 4:30 PM dose was documented as given at 10:26 PM, on 08/12/2023 the 4:30 PM dose was documented as given at 10:59 PM, and on 08/14/2023 the 4:30 PM dose was documented as given at 10:53 PM. Resident 46 had a physician order for glargine insulin twice a day. Review of the August 2023 MAR, showed 12 out of the 61 doses administered were documented as given outside of the one-hour window. One dose was documented more than four hours late on 08/19/2023 the 7:00 AM dose was documented as given at 1:44 PM. In an interview on 09/07/2023 at 9:08 AM, Staff N, LPN, stated they were still administering 8:00 AM medications. They said they looked at their report sheet and stated they had to pass medications for Residents 11, 57, 23, 62, 34, plus two more. Review of the MAR on 09/07/2023, Resident 46's 8:00 AM medications were administered late. The medications included three high blood pressure medications, pain medications all given late, at 10:50 AM. <RESIDENT 24> Review of Resident 24's August 2023 MARs, showed an order for lispro insulin before meals and to hold the insulin dose if the BG was <150. Of the 87 doses of lispro administered, 24 were documented outside of the one-hour window. Two doses were documented as given more than four hours late on 08/03/2023 the 4:30 PM dose was documented as given at 9:36 PM, and on 08/29/2023 the 4:30 PM dose was documented as given at 9:59 PM. Twice the lispro insulin was given when the BG was <150, on 08/28/2023 at 6:30 AM the BG was 144 and on 08/31/2023 at 6:30 AM the BG was 139. Resident 24 had a physician order for glargine insulin twice a day. Review of the August 2023 MAR, showed out of the 62 doses administered, 11 were documented outside of the one-hour window. On 08/012023 the 7:00 AM dose was documented as given at 1:54 PM, almost seven hours late, and on 08/09/2023 the 8:00 PM dose was documented as given at 4:09 PM, almost four hours early. <RESIDENT 12> Review of Resident 12's August 2023 MARs showed an order for Novolog (rapid acting) insulin three times a day. Out of the 92 doses of Novolog administered, ten were documented outside of the one-hour window. Three doses were documented as given more than four hours late: on 08/09/2023 the 5:00 PM dose was documented as given at 10:23 PM, on 08/11/2023 the 7:00 AM dose was documented as given at 3:24 PM, and on 08/18/2023 the 5:00 was documented as given at 11:08 PM. Review of the August 2023 MAR, showed Resident 12 had an order for glargine insulin twice daily. Review of the MAR showed eight doses were documented as given eight out of 31 times outside of the one-hour window. Review of Resident 12's MAR, dated 09/07/2023, showed all of their 8:00 AM medications were administered late. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. <RESIDENT 44> Review of Resident 44's August 2023 MARs, showed resident received nutrition via enteral tube (tube inserted through abdomen into the stomach to deliver nutrition) 24 hours a day. Resident 44 had a physician's order for Novolin sliding scale insulin (dose based on BG level), before meals and at bedtime. Of the 58 doses of Novolin administered, 30 were documented outside of the one-hour window. Resident 44 had a physician's order for glargine insulin twice daily. Of the 33 doses of glargine insulin administered, 22 were documented outside of the one -hour window. Review of Resident 44's MAR, dated 09/07/2023, showed all of their 8:00 AM medications were administered late. Review of an incident investigation, dated 09/07/2023, showed a licensed nurse administered the resident's medications late. <RESIDENT 65> Resident 65 admitted to the facility on [DATE]. Review of Resident 65's August 2023 MARs, showed a physician order for lispro insulin before meals and lispro sliding scale insulin before meals and at bedtime. The dose on 08/23/2023 at 11:30 AM was documented was given on 08/24/2023 at 5:10 PM, more than 24 hours later. Three other doses of lispro were documented as administered more than four hours late: on 08/15/2023 the 4:30 PM dose was documented as given at 10:02 PM, on 08/18/2023 the 4:30 PM dose was documented as given at 11:23 PM, and on 08/20/2023 the 4:30 PM dose was documented as given at 10:39 PM. Of the 64 doses of lispro insulin administered, 12 doses were administered outside of the one-hour window. Resident 65 has a physician order for glargine insulin at bedtime. Of the 21 doses of Glargine insulin administered, five were documented outside of the one-hour window. In an interview on 09/07/2023 at 12:16 PM, Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner, stated medications were a problem and there was no way they could finish their medications in one hour. In an interview on 09/11/2023 at 12:40 PM, Staff A, Nursing Home Administrator, stated they did not know what procedures the facility had in place for identifying medication errors. In an interview on 09/13/2023 at 12:20 PM Resident 65, stated that they did not get their medications on Saturday 09/09/2023, that the nurse walked off or called off. Resident 65 stated that they were the most concerned about their anti-rejection medication for a heart transplant that they had. Resident 65 stated that their medication was late on Monday 09/11/2023. Resident 65 stated that they have had multiple issues with getting their medication on time or at all. Resident 65 stated that they have a medication Trulicity (medication for diabetes) which was not given to them on 09/10/2023 because the nurse was not able to locate it. In a joint interview on 09/14/2023 at 2:11 PM, Staff T, Senior [NAME] President of Clinical (SVPCO) Operations, Staff U, [NAME] President of Operations (VPO), Staff A, Administrator and Staff B, Director of Nursing Services were present. Staff U said the insufficient staffing occurred overnight when they lost five staff at one time to go where previous administration went. Staff U said they had talked about looking into the medication administration times and schedules. Staff U said the facility had just had not completed this yet and then they had more staff leave. <SEPTEMBER 7, 2023 - LATE ADMINISTRATION FOR 20 ADDITIONAL RESIDENTS> Review of the MARs, dated 09/07/2023, showed a total of 29 residents received their scheduled 8:00 AM medications late which was over one-hour outside of the prescribed scheduled time to include drugs from various drug classes. Similar findings were found through record review of the September 2023 MAR, showed 20 additional residents were impacted regarding late medication administration on 09/07/2023 for their scheduled 8:00 AM (on both units) that included Resident 7, 14, 15, 27, 28, 30, 31, 36, 43, 45, 47, 52, 54, 64, 68, 124, 275, 276, and 278 and 376. Review of the 09/07/2023 AM staffing sheets, showed there were three nurses worked on Unit 1, and two nurses worked on Unit 2. Review of an incident investigations, dated 09/07/2023, showed a licensed nurse administered Resident 7, 15, 27, 28, 30, 31, 36, 43, 45, 47, 52, 54, 64, 68, 124, 275, 276, 278, and 376's medications late. There was no medication incident report available for Resident 14 for review. In an interview on 09/07/2023 at 12:20 PM, Staff B stated we know we have a staffing problem. The staff do not even want to pick up another shift. They were working 16-hour shifts and were burned out. <SEPTEMBER 9, 2023 - MISSED MORNING MEDICATION ADMINISTRATION FOR 18 RESIDENTS> <RESIDENT 18> Review of Resident 18's September 2023 Medication Administration Record (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 18 missed included Apixaban 5mg at 8 AM for treatment of Atrial Fibrillation (an irregular heart rhythm that begins in your heart's upper chambers), Torsemide to treat fluid retention related to heart failure at 8 AM, Metoprolol Succinate ER to treat high blood pressure at 8 AM, Levothyroxine to treat thyroid condition at 8 AM, and Quetiapine for psychosis (also known as Seroquel) at 8 AM. <RESIDENT 57> Review of Resident 57's September 2023 (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 57 missed included; Humalog (Lispro Insulin) on sliding scale for diabetes at 7:30 AM, Carbidopa-Levodopa 25-100mg - 2 tablets for Parkinson's Disease at 8 AM, Hydrochlorothiazide 25mg for high blood pressure at 8 AM, Finasteride 5mg for BPH (enlarged prostate) at 8AM, Hydrochlorothiazide 25mg for high blood pressure at 8 AM, Metoprolol Succinate 50mg high blood pressure at AM, Midodrine 10mg for high blood pressure at 8 AM, and Olmesartan Medoxomil 40mg for high blood pressure at 8AM. <RESIDENT 22> Review of Resident 22's September 2023 (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 22 missed included; Baclofen Tablet 10mg (2 tablets) for pain at 9AM, Bumex 2mg for Edema at 9 AM, Empagliflozin 10mg for type 2 diabetes at 8 AM, Escitalopram 20mg for major depressive disorder at 8 AM, Metformin 1000mg for type 2 diabetes at 8 AM, Humalog 30 units for type 2 diabetes at 8 AM (blood sugar at 12PM was 260), Insulin 60 units for type 2 diabetes at 7am, Metoprolol Tartrate 12.5mg for high blood pressure at 8 AM and Sitagliptin Phosphate 100mg for type 2 diabetes at 8 AM. <RESIDENT 12> Review of Resident 12's September 2023 (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 12 missed included; Novolog (Aspart Insulin) 3 units for blood sugar management at 7 AM. Of note Resident 12's Blood sugar at 11:00 AM was 273, Amlodipine 10mg for high blood pressure at 8 AM, Carbidopa-Levodopa 25-100mg for Parkinson's disease at 8 AM, Gabapentin 100mg 2 capsules for diabetic neuropathy (type of nerve damage that can occur with diabetes and can cause pain) at 8 AM and Lisinopril 10mg for high blood pressure at 8 AM. <RESIDENT 24> Review of Resident 24's September 2023 (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 24 missed included; Digoxin 250 mcg for Atrial fibrillation at 8 AM, Insulin Lispro 6 units for blood sugar management at 6:30 AM, Lantus Solo Start Pen Injector 22 units for blood sugar management at 7 AM, Metoprolol Succinate ER 100mg at 8AM and Lorsartan Potassium 25mg at 8 AM. <RESIDENT 376> Review of Resident 376's September 2023 (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 376 missed included; Amlodipine 5mg (two tablets) for high blood pressure at 8 AM and Cozaar 50 mg for high blood pressure at 8AM. <RESIDENT 47> Review of Resident 47's September 2023(MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 47 missed included; Finasteride 5mg for BPH (enlarged prostate) at 8 AM, Lisinopril 10mg for high blood pressure at 9 AM and Midodrine 2.5mg for high blood pressure at 8 AM. <RESIDENT 46> Review of Resident 46's September 2023 (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 46 missed included; Bupropion 50mg for major depressive disorder at 8 AM, Clopidogrel Bisulfate 75mg for history of stroke between 7am-12, Flovent HFA Aerosol 110MCG/ACT 2 puff inhale orally for COPD in the AM, Fluoxetine HCL 40mg for Major Depressive Disorder in the AM, Humalog 16 unites before meals for type 2 diabetes at 6:30 AM (blood sugar check at 11:30 AM was 405), Metoprolol Tartrate 25 mg for high blood pressure at 8 AM and Insulin Glargine 15 units for type 2 diabetes at 7 AM. <RESIDENT 41> Review of Resident 41's September 2023 (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 41 missed included; Amlodipine 5 mg (2 tablets) for high blood pressure at 8 AM, Duloxetine HCL 30mg (2 capsules) for pain at 8 AM, Gabapentin Capsule 300 mg for neuropathy/pain at 8 AM, Glipizide 10 mg for type 2 diabetes mellitus at 8 AM, Lisinopril 40mg for high blood pressure at 8 AM, and Oxycodone HCL 5mg for chronic pain at 8 AM. <RESIDENT 28> Review of Resident 28's September 2023 Medication Administration Record (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 28 missed included; Enoxaparin Sodium Solution 40mg/0.4ml inject 40mg subcutaneous (under the skin) for DVT (Deep Vein Thrombosis- blood clot) prophylaxis (preventative) at 8 AM, Gabapentin 200mg for pain at 8 AM and Metoprolol Tartrate 50 mg for high blood pressure at 8 AM. <RESIDENT 17> Review of Resident 17's September 2023 (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 17 missed included; Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH 1 puff inhale for COPD at 8 AM, Lisinopril 10 mg for high blood pressure at 8 AM and Metoprolol ER 25mg for high blood pressure at 9 AM. <RESIDENT 29> Review of Resident 29's September 2023 (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 29 missed included; Brimodidine Tartrate Solution 0.2% instill 1 drop in left eye for glaucoma at 8 AM Cosopt PF Solution 22.3-6.8 mg instill 2 drops in left eye for glaucoma at 9 AM, Depakote Tablet Delayed Release 250 mg for bipolar disorder at 8 AM Furosemide 0.5mg for Chronic Heart Failure at 8 AM, Hydroxyzine 50mg for anxiety at 9 AM, Lisinopril 20 mg for high blood pressure at 8 AM, Metoprolol Succinate ER 25mg for high blood pressure at 8AM, Pyridium 200 mg for UTI pain at 8 AM and Synthroid 100 MCG for hypothyroidism at 7 AM. <RESIDENT 7> Review of Resident 7's September 2023 (MAR), they missed medications on 09/09/2023 which could have had adverse consequences. The most clinically significant medications that Resident 7 missed included; Glycopyrrolate 1mg for increased secretions 1mg 8 AM, Lisinopril 10mg for high blood pressure for 8 AM, Metformin 1000mg for high blood pressure for diabetes mellitus at 8 AM and Cleanse MA[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines (IPC) and standards of practice for 2 of 2 units (Station 1 and 2) reviewed for IPC procedures. The facility failed to ensure that residents had transmission-based precautions (TBP) in place for 9 of 9 residents (Residents 14, 9, 61, 20, 15, 35, 278, 56 and 8), staff completed hand hygiene consistently, Personal Protective Equipment (PPE) was used appropriately, and that cross contamination did not occur during a CRAB (Carbapenem-resistant Acinetobacter baumannii) OXA (oxacillinase) (CRAB OXA - Acinetobacter bacteria that affects residents within health care settings that is difficult to treat and is identified as a multi-drug resistant organism MDRO) outbreak. These failures led to three residents (Residents 26, 25, and 42) to experience a facility acquired infection with CRAB OXA and placed all residents and staff at risk for potential exposure to CRAB OXA or other infections and a decreased quality of life. On 08/30/2023 at 5:48 PM the facility was notified of an Immediate Jeopardy (IJ) situation related to CFR 483.80 (a)(1),(2)(i)(iii)(iv)(A)-(vi) F880, Infection Prevention & Control, related to the facility's failure to prevent the spread of CRAB OXA to three residents during a facility outbreak on Station 1 which could lead to serious harm or potential death as the bacteria is resistant to many antibiotics and difficult to treat. Station 1 is a specialized unit of residents who have respiratory conditions and require breathing assistance through tracheostomies (artificial opening on the neck used for an airway) and/or the use of ventilators (machine that helps resident breathe by pumping air into the lungs). The facility failed to implement the proper use of PPE, monitor staff's adherence to ICP practices, failed to ensure adequate hand hygiene practices were followed, and failed to ensure cross contamination did not occur. These failures have been occurring since 04/20/2023 when the Local Health Jurisdiction (LHJ) requested a meeting with facility management due to their observations of continued breaks in infection control practices. The IJ was removed on 09/05/2023 after onsite validated by surveyor when all staff education was completed for TBP, hand washing, standards of IPC, identification, and placement of residents in correct TBP, and providing education related to IPC practices to vendors and visitors who entered the facility. After removal of the IJ, the deficient practice at F760 remained at a E scope and severity, a pattern with no actual harm, with potential for more than minimal harm, following the removal of the IJ. Findings included . Review of the Centers for Disease Control (CDC) article titled, Acinetobacter in Healthcare settings, dated 11/13/2019, showed persons most at risk to obtain an infection are residents on breathing machines (ventilators) and/or have a catheter (tube inserted into bladder), or open wounds. The bacteria may spread by contact with contaminated surfaces or equipment that was not adequately disinfected or through person to person spread via contaminated hands. Review of a facility policy titled, Enhanced Barrier Precautions, dated 08/01/2023, showed that residents with an indwelling medical device (enteral feeding tube, urinary catheter, tracheostomy, or ventilator) who reside on a unit where residents are known to be infected or colonized with targeted MDRO should be placed on Enhanced Barrier Precautions (EBP): - An appropriate EBP or Contact Precaution (CP) sign will be posted on the resident room door. - Gown and gloves are required prior to a high contact care activity with residents such as dressing, bathing, transferring, providing hygiene, assisting with toileting, or changing linens. - Perform hand hygiene when exiting room. Review of a facility policy titled, Wound Dressing: Aseptic (clean not sterile technique), revised on 12/01/2021, showed staff should apply clean gloves, remove the resident's soiled dressing, perform hand hygiene, apply new gloves, then cleanse the wound and apply the wound dressing. <CRAB OXA> In a virtual meeting between surveyors, the LHJ and Washington State Department of Health (DOH) staff on 08/29/2023 at 9:00 AM, Collateral Contact 7 (CC7), epidemiologist at the Snohomish Health Department (SHD), reported they observed breaks in infection control practices during visits to the facility, dating back to April 2023, when they had a meeting with facility management. CC7 stated the facility had not contained the CRAB OXA outbreak, and the facility had developed another case in July 2023. Review of facility line listing for CRAB OXA outbreak, provided by facility on 08/29/2023, showed five residents listed as diagnosed with CRAB OXA. On 08/29/2023 at 2:41 PM, Staff T, [NAME] President of Clinical Operations, provided a document that they stated was minutes from a meeting between the LHJ, DOH, and facility staff, dated 04/20/2023. Staff T stated this was the first time they were aware the LHJ had concerns with the facilities infection control practices. RESIDENT 25 Resident 25 admitted to the facility on [DATE] with diagnoses of chronic respiratory failure and ventilator dependent. Review of the census data in the medical record showed the resident resided in rooms on the specialized respiratory unit (Station 1). Review of Resident 25's clinical record showed that they were tested for CRAB OXA on 07/19/2023 and the results were positive. RESIDENT 26 Resident 26 admitted to facility on 09/14/2021 with diagnoses of chronic respiratory failure, lung disease and ventilator dependent. Review of the census data in the medical record showed that resident resided in rooms on the specialized respiratory unit (Station 1). Review of Resident 26's clinical record showed they had been tested for CRAB OXA on 03/08/2023 and 03/29/2023 and both tests were negative for the organism. On 05/09/2023, Resident 26 was tested for CRAB OXA, and the results were positive. RESIDENT 42 Resident 42 admitted to the facility on [DATE] with diagnoses of chronic respiratory failure, lung disease and ventilator dependent. Review of census data in the medical record showed that resident resided in rooms on the specialized respiratory unit (Station 1). Review of Resident 42's clinical record showed that they had been tested for CRAB OXA on 02/17/2023 and the results were positive. During an interview on 08/29/2023 at 10:21 AM, Staff E, Infection Preventionist (IP)/Licensed Practical Nurse (LPN), stated the CRAB organism liked warm moist environments, which was why the residents on the respiratory unit were at highest risk, and CRAB had a high mortality rate. Staff E stated good hand hygiene was the most important thing to prevent the spread of the CRAB organism to others. During a phone interview on 09/06/2023 at 12:26 PM, CC7 stated the LHJ listed residents that tested positive for CRAB OXA at the facility were facility acquired infections (an infection acquired while residing in the facility). CC7 stated obviously the resident that tested negative twice and then tested positive at the facility would be considered a facility acquired infection, but the prevalence of CRAB OXA within Washington State was low, so unless there had been another known exposure, the LHJ linked all the facility positive tests to the current facility outbreak. During an interview on 09/11/2023 at 11:06 AM, Staff E stated if a resident tested positive for CRAB OXA at the facility, it would be considered a facility acquired infection. <CROSS CONTAMINATION> During an observation on 08/29/2023 at 1:18 PM, Staff UU, housekeeper, was cleaning room [ROOM NUMBER]. There was a sign for contact precautions posted on the wall outside of the room and a PPE supply bin outside of the door. Staff UU was observed coming out of the room after cleaning the bathroom, placed a garbage bag into the garbage bin on the housekeeping cart while wearing gloves, then with the contaminated gloves obtained a new garbage bag off the roll of bags on the cart. Staff UU, with the same contaminated gloves, went back into the bathroom, returned to the housekeeping cart, placed the used cleaning cloth over the handle of the cart, obtained a clean mop head from the container, and attached it to the mophandle without changing their contaminated gloves. As Staff UU was mopping, part of the mop handle touched the resident in bed A's (bed closest to door) catheter bag. Staff UU was observed to remove the soiled mop head and placed it over the handle of housekeeping cart and put the mop handle onto the cart without disinfecting it. Staff UU then removed their gloves and completed hand hygiene. Staff UU, with bare hands, removed the used mop head and the used cleaning cloth from the handle of the housekeeping cart, and placed them into plastic bags, then was observed to perform hand hygiene. Staff UU, pushed the housekeeping cart by the contaminated handle to the shower room, obtained a clean mop head, opened the door, and entered the shower room. Staff UU was not observed to disinfect the housekeeping cart handles or the shower room doorknob, entered the shower room, then donned gloves without performing hand hygiene. On 08/30/2023 at 8:18 AM, the Station 1 shower room was observed to have a personal electric razor labeled with Resident 42's name (a resident known to be diagnosed with CRAB OXA) was sitting on top of folded towels, hospital gowns, and a bath blanket that were on top of the plastic and mesh barrel. On top of the folded linens were individual containers of barrier cream and body lotion that appeared to have been used as they were not full. There were also two white socks that were not folded laying with the linens but did not appear dirty. Next to the shower chair, that was in the stall area, was a bath bench with a square pink bin full of no rinse soap, conditioner, shaving cream, aftershave, a hair pick with strands of hair in it, and a disposable razor without the blade guard and had small hairs within the blades. The bottles within the bin appeared to have been used. The bin had partially dried white liquid pools that resembled liquid soap covering the bottom. On the wall in the shower room was a sign that stated, Not to leave personal items in shower room. During an observation and interview on 08/30/2023 at 8:23 AM, Staff E joined the surveyor in the shower room. Staff E stated all residents should have their own supply of grooming items and bottles should not be shared between residents. Staff E stated personal items were not to be left in the shower room and they should not be placed on top of clean linens. Staff E stated the disposable razor had been used and that it should have been disposed of in the sharp's container (medical waste container that is puncture- resistant). Staff E stated since Resident 42's razor had been in the shower room; it had contaminated the area and the linens needed to be removed and the area disinfected. During an observation on 08/30/2023 at 1:12 PM, Staff BB, NAC, and Staff CC, NAC, were observed to use the mechanical lift in room [ROOM NUMBER] and then push it into the hallway, along the wall. They were not observed to disinfect the lift machine after use. During an observation on 08/30/2023 at 2:34 PM, Staff EE, NAC, was observed coming out of the clean linen room with a large stack of bath blankets held against their clothing. During an observation on 09/07/2023 at 9:12AM, Staff O, LPN, returned to the medication cart from a resident's room, cleaned the stethoscope using a disinfectant wipe without wearing gloves and then resumed medication pass touching the computer screen without performing hand hygiene. <PPE> During an observation on 08/29/2023 at 10:30 AM, Staff Y, NAC, was observed with their procedure mask positioned with their nose exposed. Staff Y was then observed to reposition their mask by pulling on the top front of the mask, and no hand hygiene was completed. Staff Y stated they had a difficult time keeping the procedure mask properly placed over their nose. During an observation and interview on 08/30/2023 at 2:49 PM, Staff P entered room [ROOM NUMBER] B (bed next to the window) that had a sign posted showing the resident was on EBP. Staff P did not don PPE prior to entering room and was observed to assess the resident's abdomen and administer water and medications thru an enteral tube (tube inserted through abdomen into stomach to deliver nutrition and medications). Staff P stated that they should have worn a gown, but stated they did not fully understand what EBP was for. <Hand Hygiene> During an observation on 08/29/2023 at 12:54 PM, Staff P was observed connecting the intravenous (IV) medication (medication given in liquid form through a tubing that is inserted into the vein) to Resident 278's IV line. After applying gloves and cleaning the hub (the access point) of the resident's IV line, Staff P, with gloved hands grabbed the garbage can and pulled it closer to them. Staff P then primed (filled the tubing with fluid, removing the air so that it can be safely connected to the resident) the IV tubing for the medication and connected the tubing to the resident's IV line. Staff P did not change gloves or complete hand hygiene after touching the garbage can before they connected the resident's IV. Staff P stated they had moved the garbage can and had not changed their gloves prior to connecting the IV line. On 08/29/2023 at 1:03 PM, Staff N, LPN, was observed doing a bandage change on Resident 16's head wound. After Staff N removed the used bandage and discarded it, Staff N did not remove their gloves or perform hand hygiene. Staff N stated that he double gloved so that they did not have to do hand hygiene during the bandage change. During an observation on 08/30/2023 at 2:13 PM, Staff Z was observed at the bedside of a resident that had a sign posted showing that resident had EBP. Staff Z was observed leaving the room and did not perform hand hygiene. During an observation on 09/01/2023 at 12:15 PM, Staff P was observed to remove a gown from the storage bin outside room [ROOM NUMBER], donn the gown, and then completed hand hygiene using hand gel. <TBP> In a virtual meeting on 08/29/2023 at 9:00 AM, CC7 stated facility was notified by the LHJ and the DOH on 08/22/2023, that all residents on the specialized respiratory unit (Station 1) and any residents with an indwelling medical device on Station 2 needed to be placed in EBP. RESIDENT 14 Resident 14 resided on the same unit as residents with CRAB OXA infections. During an observation on 08/29/2023 at 1:27 PM, a storage bin with PPE supplies was noted outside of Resident 14's doorway. There was no sign present to alert staff of what type of TBP was required to enter the room. During an interview on 08/29/2023 at 1:28 PM, Staff O, LPN, stated Resident 14 was on contact precautions related to an infection with a MDRO and the resident had an intravenous access. RESIDENT 9 Resident 9 resided on the specialized respiratory unit and the same unit as the residents with the CRAB OXA cases. Review of Resident 9's medical record showed that they had an enteral feeding tube and a tracheostomy. During an observation on 08/29/2023 at 1:27 PM, no TBP sign was posted outside of Resident 9's room, nor was there a supply of PPE outside of the room to use before you entered. On 08/29/2023 at 12:47 PM, Staff S, Respiratory Therapy Manager, stated residents that have a portal of entry such as catheter, tracheostomies or use of a ventilator should be on EBP. Staff S stated they did not know why Resident 9 did not have a EBP sign or bin of PPE supplies outside of their door. RESIDENT 61 Resident 61 resided on the specialized respiratory unit and the same unit as the residents with the CRAB OXA cases. Resident 61 was noted to have a tracheostomy. During an observation on 08/29/2023 at 2:00 PM, no TBP sign was posted outside of Resident 61's room, nor was there a supply of PPE outside of the room to use before you entered. During an interview on 08/29/2023 at 10:21 AM, Staff E stated they were not familiar with the facility policy for EBP, and their understanding was residents were on EBP on Station 1 if they had a respiratory condition. Staff E could not elaborate why not all residents on Station 1 with a respiratory condition were on EBP. RESIDENT 56 Resident 56's clinical record showed they had an enteral tube in place. During an observation on 08/29/2023 at 2:10 PM, no TBP sign was posted outside of Resident 56's room, nor was there a supply of PPE outside of the room to use before you entered. RESIDENT 15 Resident 15's clinical record showed they had a urinary catheter in place. During an observation on 08/29/2023 at 3:32 PM, no TBP sign was posted outside of Resident 15's room, nor was there a supply of PPE outside of the room to use before you entered. RESIDENT 35 Resident 35's clinical record showed they had an enteral tube in place. During an observation on 08/29/2023 at 3:32 PM, no TBP sign was posted outside of Resident 35's room, nor was there a supply of PPE outside of the room to use before you entered. RESIDENT 278 Resident 278's clinical record showed they had an IV line in place. During an observation on 08/29/2023 at 3:32 PM, no TBP sign was posted outside of Resident 278's room, nor was there a supply of PPE outside of the room to use before you entered. RESIDENT 20 During an interview on 08/28/2023, Resident 20 stated they had pressure ulcers (bed sores) on their buttocks. During observations on 08/28/2023 at 11:49 AM and 08/29/2023 at 10:25 AM, no TBP sign was posted outside of Resident 20's room, nor was there a supply of PPE outside of the room to use before you entered. RESIDENT 8 Resident 8's clinical record showed they had an enteral tube in place. During an observation on 08/29/2023 at 2:10 PM, no TBP sign was posted outside of Resident 8's room, nor was there a supply of PPE outside of the room to use before you entered. <OTHER> During an observation on 08/30/2023 at 2:49 PM, Staff P was observed to fill an enteral administration bag, dated 08/29/2023 at 1:00 PM, with formula. Staff P stated enteral bags were to be changed every 24 hours. Staff P discarded the outdated enteral administration bag after prompted by surveyor. During a meeting on 09/07/2023 at 12:17 PM, with Staff A, Administrator, Staff B, Director of Nursing Services, Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner, and the surveyors, Staff B stated nurses were working short staffed and were burned out. CC2 stated because nurses were burned out and working short staffed, they were going to make mistakes, which included not following standards of IPC practices. WAC Reference 388-97-1320 (1)(a)